Polypharmacy: How widespread is the practice?

New Delhi: Monika, a migraine patient, felt as if a thick fog has descended on her brain, as once again she felt heavy and drowsy while reading the prescription letter to take another dose of afternoon pills.

She feels lethargic and inactive to perform her daily household tasks, her children becoming less dependent on her considering her body’s refusal to serve them food or pack a box of lunch.

She sleeps more than usual and doesn’t take much part in social gatherings. This was not until few years ago when she started her course of medications.

Earlier, she felt acute headache but she felt good most of the time. In fact, Monika was absolutely fine — the real problem started when the dozens of tablets she had been prescribed by her doctor started upsetting her health.

Till recently, Monika was on a cocktail of more than 15 pills, from an anti-hypertensive drug for high blood pressure to painkillers and arthritis. The prescriptions had been increasing during a 10-year period. On one fine day, she gave up and decided to live a drug free life, whatever time of the life she is left with. Within days her mood lifted, she felt young and energetic and less dependent. Though, shots of migraine do bother her, but she has now resorted to traditional methods of yoga and meditation to control it to some extent.

Monika is one of a growing number of patients in the country who are on a daily cocktail of drugs to treat medical conditions. As the drugs, which are initially given for genuine ailments, start creating new symptoms as side-effects, the patient gets more and more drugs prescribed to deal with the side-effects of earlier prescribed medication.

Nowadays, it is common for a patient to pop four-five pills for a minor health problem, which seems more of a burden than a solution to the respective health issue.

Recently, AIIMS Bhubaneswar director Dr A K Mohapatra expressed concerns about doctors prescribing too many medicines. He said within seconds after a patient goes to a doctor, many have a tendency to write down several medicines without even properly examining the patients and without going into the biological behaviour of drugs.

This trend of doctors to immediately take out their prescription pad and write multiple medicines without even properly examining the patient points to a sad state of affair. The trend of polypharmacy is fast setting in the medical field.

Dr S P Kalantri, director and professor of medicine, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram (Maharashtra) in a frank conversation with AalaTimes said, “Shot-gun therapies are common, particularly for patients with medically unexplained symptoms and acute undifferentiated fevers — to name just two medical disorders. It is not uncommon to see a patient receiving several antibiotics, antimalarials, vitamins, pain killers, antacids and an antihistaminic when they seek medical attention for acute fever.”

“I believe that doctors resort to polypharmacy because of lack of adequate training during their undergraduate days, not being able to pick up disorders by good history and focused physical examination and misguided belief in the powers of polypharmacy — at least some drugs would work. Also, lack of access to cheaper diagnostics boosts this practice. For example, if rapid tests for the diagnosis of malaria are available at the point of care and are priced such that patients are able to afford the costs, doctors might use anti-malarial judiciously and not indiscriminately,” he said.

Dr Niteen V Dhepe, medical director, SkinCity Postgraduate Institute of Dermatology, Pune told AalaTimes, “It is common in busy practices where you see many patients and routine patients. For example, in general practices, government hospital practices, and physicians who see more than 60 cases a day. In these cases treatment is stereotyped and symptomatic. In specialty practices it is not a common trend unless one is seeing literally 100s of cases a day.”

“The practice is not as widespread as it is thought out to be as many drugs are supportive, adjuvant and empirical. Like antacids, vitamins etc. Ideal practice should be documented diagnosis on prescription paper and one or two drug prescription. This will have lower patient satisfaction and high cost of diagnostics,” he added.

Dr R K Sharma, director, Institute of Education and Research, Noida, told AalaTimes, “It is true that most of the doctors in private practice write more medicines to patient, much more than required. Statins are grossly abused. Vitamin E is another medicine often overprescribed and such practice is rampant.”

Dr Guru Prasad Mohanta, professor of pharmacy at Annamalai University, Chennai, told AalaTimes, “This is a serious issue! The patients often understand this but are helpless and have not enough courage to show their concern or even ask about the prescription. The profession is being commercialized and the vested interest becoming more prominent. In my opinion, it is not that all the medicines that are prescribed are needed by the patient, but the doctor needs to sell them.”

“This is rampant in private sector including outpatient clinics of hospitals. But many of these medicines do not fall in serious therapeutic category. They belong to vitamins, tonics, gastric antacids, acid reducing agents and sometimes antibiotics. In public sector, it is very less,” he added.

There is no dispute that for many people, prescriptions are beneficial, even lifesaving in many instances. But in most of the cases polypharmacy is either entirely unnecessary or dangerous. A drug is used to treat a problem that, although in some cases susceptible to a pharmaceutical solution, could first be treated with common sense lifestyle changes. Problems such as insomnia and abdominal pain often have causes that respond very well to counselling, and often the physician can uncover these causes by taking a careful history.

The problem is partly due to prescribers being too quick to medicate — without always checking what other medication the patient is already on. Sometimes the dearth of knowledge about the drug also affects both patients and doctors.

As the area of drug prescription is a complicated and deeply researched field, drugs should be prescribed after proper analysis of its possible side effects and risk-benefit calculations. As what may work for one person may be absolutely inappropriate, or even harmful, for someone else. A patient, at the receiving end, spends a considerable amount of time and resources in correct and timely treatment. The indiscriminate prescription of drugs cost him dear.

“Reasons for overprescribing drugs could be many. First, costly medicines are written to please pharma companies and chemists. Greed of more money is common reason. It cannot be stopped,” said Dr R K Sharma.

Dr Guru Prasad Mohanta said, “There is a nexus between pharma companies and doctors. Doctors need to improve sales or revenue to get benefited in one or the other way. Often, the doctor has own pharmacy to sell medicines, generating revenue!”

According to Dr Mohanta, there are two issues involved: over use of medicines, which is harmful to patients as well as the society, and economic consideration — cost to the patient. The patient often borrows money to buy the medicines. There are reports, which suggest the cost of medicines alone brings the millions below the poverty line. It is estimated that the patient spends around 75 per cent of the health cost on medicines only.

Talking about the measures to curb this practice, Dr Mohanta said compulsory medical insurance might help in some way as the insurance companies pay only for those medicines, which are necessary. Prescription auditing is an option but would have no effect in the private sector. Also, once the patients realise that they are being harmed by over prescription (due to unnecessary medicines), they would drag the doctors to court seeking compensation. This would automatically discourage this practice and they would be more rational. Patient education is vital and they need to be educated to exert their rights.

Dr S P Kalantri said, “High-quality medical education, introduction of principles of evidence-based medicine in the medical education, attention to medical history and physical examination in the medical diagnosis and understanding the diagnostic accuracy of each investigation that the doctors order could be some of the ways the practice could change. ‘Cuts and commissions’ is also a key factor.”

He said, “Doctors need to understand that ‘large and many’ is not necessarily better, but appropriate use of rational drugs in the clinical practice can help them serve their patients in a scientific and cost-effective manner. Unfortunately, younger generations have few role models left to emulate and learn from, and the art and science of medicine is getting rapidly eroded by the commerce of modern medicine. Nobody teaches them how to choose a proper drug and how low-priced drugs are as good as, if not better than, their high-priced counterparts.”

“To illustrate, atorvastatin, the most commonly used drug to lower lipid levels has more than 100 brands available in the market and the cost of 10 mg atorvastatin ranges from Re 1 to Rs 18. Doctors are free to choose the drug company and the brand of a drug and patients in India do not have enough courage to question their doctors if they could as well be helped by low-cost drugs. Even in tertiary care hospitals, it is a standard practice to prescribe therapies that don’t work but are very expensive: for example, the use of colloids in the treatment of hypovolemic shock, use of human albumin for treating hypoalbuminaemia, and inappropriate use of expensive antibiotics in the treatment of sepsis. The list is long,” Dr Kalantri added.

The primary influence in promoting overprescribing of drugs is the pharmaceutical industry. The mind-altering properties of drug promotion and promotional campaigns often create an information vacuum between promoters and doctors.

The ignorance of physicians and the dearth of time and interest to keep themselves updated with the latest drug related information from credible medical literature often cost heavy to their patients. Another possible reason that may sway doctors towards prescribing a particular drug is somewhat biased drug research reports sponsored by drug companies and published in medical journals.

Dr Mohanta said, “It is obvious the doctors would find it difficult to keep themselves updated on medicine related information. New medicines, often in sophisticated delivery system, are being introduced. New information is made available through continuing research. This information is essential for safe and effective use of medicines. The medical representatives’ intention is to improve the sale of medicines. The information provided by them is often biased and withholds the adverse effects of the medicines. Even, they do not inform the doctors about the medicine’s cost. The doctors are often in dark about the cost effectiveness of the alternatives.”

He further said, “Doctors have limited time at their disposal. They can be made aware of or can be provided with independent and unbiased information through many ways such as Drug Information Newsletter from independent agency and establishing hospital or independent Drug Information Centres. There are many such centres functioning in the country but their services are not properly promoted. Many of the pharmacy colleges have Drug Information Centres. The World Health Organisation (WHO) advocates the establishment of Drug Information Centres to promote appropriate use of medicines.”

Expressing a different opinion, Dr R K Sharma said, “I do not agree that doctors prescribe medicines without having knowledge of the drug and its effects, as doctors are supposed to know about the side effects of drugs before prescribing them.”

Dr S P Kalantri said, “It is a shame that doctors rely on medical representatives to learn the indications for drugs. This source of information is biased, commercially driven, and more often than not, is not data-driven or evidence-based. Doctors fail to understand that medical representatives visit them to boost the sales of the companies they represent, and the handouts they deliver and the freebies they offer to the prescribers are cleverly meant to promote the company’s products.”

“This might sound harsh, but at Mahatma Gandhi Institute of Medical Sciences, Sevagram — a non-profit teaching hospital — beginning 2009, I banned the entry of medical representatives in the hospital. Also, we started our own Formulary where we provide access to close to 600 low-cost drugs. These measures have helped us reduce the prescription of unnecessary drugs and bring down the cost of healthcare substantially. For example, our patients with diabetes mellitus, high blood pressure, coronary artery disease and high lipid levels now pay just over Rs 100 a month to have their four medically important disorders scientifically treated.”

There is no doubt that drug therapy has improved the lives of many patients. Medications can be used to effectively treat patients regardless of their age. When drugs are used judiciously and thoughtfully, there’s a much better chance of treating diseases. A doctor can ensure that patients get safe and effective drug therapy by carefully monitoring the history, progress and being alert for signs of trouble. Polypharmacy is not a one stop solution for minutest to bigger health problems.

Sensitization of doctors on the ill effects of over prescription and the benefit of rational use of medicines is one way to discourage this bad practice. Patients also have the onus to carefully watch their health standard during the course of the treatment and question any over prescription of drugs.

Raising physicians’ as and well as patients’ awareness of polypharmacy may help to ensure safe, effective and appropriate use of medication